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WESTERN WISCONSIN HEALTH 1100 BERGSLIEN ST BALDWIN, WI 54002 March 3, 2020
VIOLATION: PROVISION OF SERVICES Tag No: C1004
Based on record review and interview the facility failed to develop and implement policies and procedures to ensure psychiatric patients, who presented to the Emergency Department with suicidal ideation and/or suicide attempt, were reassessed and provided appropriate interventions to ensure a safe, secure environment. This failure had the potential to affect all patients who presented to the ED with suicidal ideation and/or suicide attempt. (Refer to Tag C1006)
VIOLATION: PATIENT CARE POLICIES Tag No: C1006
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review and interview staff failed to reassess and provide continued monitoring according to patients' needs in 5 of 5 patients (Pts. #3, 10, 14, 16, and 22) who presented to the emergency room (ER) with suicidal ideation or suicide attempts in a total universe of 24 medical records reviewed.

Findings:

Review of facility Policy #SOC1603 "Mental Health" effective date 4/10/00 revealed content related to procedure for "Emergency Detention - Chapter 51.15" and "Voluntary Psychiatric hospitalization ". It does not address interventions or suicide precautions for mental health patients.

Review of facility Policy #ED1643 "Triage Process in the Emergency Department (ED)" effective date 5/08 revealed, "...The RN triages patients presenting to the ED to assess acuity level of injury or illness...Definitions: 2. Emergency Severity Index (ESI) - a 5 level triage system that classifies patients in the following categories: a. Level 1 - requires immediate Life-Saving Intervention b. Level 2 - High risk situation, confused/lethargic/disoriented or sever [sic] pain/distress. Require high resource intensity c. Level 3 - condition that have the potential for complications or increase in severity, which require medium resource intensity..."

Review of Pt. #3's medical record on 3/2/20 revealed a [AGE] year old admitted on [DATE] at 3:09PM with suicidal ideation. The "ED Nursing Notes" revealed, under "Patient Story", that the patient stated "there were voices telling her to take a kitchen knife and stab her heart. Patient is in tears and anxious upon arrival ..." The record revealed a Columbia-Suicide Severity Rating Scale (an evidence based questionnaire used for suicide assessment) was performed at 3:21PM by the ED nurse with the severity level assessed at "HIGH (Red)." The Emergency Severity Index Acuity (a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs) was documented at "2 (Emergent)." The record revealed the ED provider saw the patient at 3:19PM. Labs were drawn. A Tele-psychiatry consult by Health Partners was performed at 4:45PM. The Health Partners note revealed, "Suicide Risk Level High ... Pt. was unable to contract for safety and did not trust herself to return home..." ED Provider Notes "Impression and Plan" time stamped at 6:34PM revealed, "no medical concerns or signs on exam to warrant medical admission. She is medically cleared for psychiatric admission." Pt. was transferred and voluntarily admitted to a Behavioral Health Unit at Hospital B at 7:19PM.
There is no documentation in the medical record to demonstrate ongoing nursing assessments or suicide precautions taken for the 4 hours and 10 minutes while a patient in the ER. The record reveals one set of vital signs on admission at 3:18PM.


Review of Pt. #10's medical record on 3/2/20 revealed a [AGE] year old admitted on [DATE] at 6:02PM with suicidal ideation and alcohol abuse. The "ED Nursing Notes" revealed, under "Patient Story", "Pt. states that she either wants to hang herself or shoot herself in the head. Pt. does have a hx (history) of attempt in high school where she tried to hang herself but the rope broke." The record revealed a Columbia-Suicide Severity Rating was performed at 6:32PM by the ED nurse with the severity level assessed at "HIGH (Red)". The Emergency Severity Index Acuity was documented at "2 Emergent". The record revealed the ED provider saw the patient at 6:10PM. Labs were drawn. A Tele-Psychiatry consult by Health Partners was performed at 8:15PM. The Health Partners note revealed, ""Suicide Risk Level Moderate... Pt was agreeable to return home tonight and denied current suicidal ideation when interviewed by this writer..." Record revealed "ED Provider Notes ED Course: 8:59PM case discussed with [tele-psych provider name] She has chronic suicidal thoughts. She has no ability to act on those thoughts. She is currently intoxicated... Final Clinical Impression/Plan: Patient is not actively suicidal. She can contract for safety tonight...she was medically cleared for admission. No beds available tonight. Disposition: Discharge." Written discharge instructions were given and the patient was discharged to home with her significant other at 10:31PM.
There is no documentation in the medical record to demonstrate ongoing nursing assessments or suicide precautions taken for the 4 hours and 29 minutes while a patient in the ER. The record reveals vital signs on admission at 6:21PM and at 9:13PM.


Review of Pt. #14's medical record on 3/2/20 revealed a [AGE] year old autistic patient admitted on [DATE] at 7:07PM with suicidal ideation and suicide attempt by running away without appropriate clothing or shoes in the cold weather. The record revealed a Columbia-Suicide Severity Rating was performed at 7:15PM by the ED nurse with the severity level assessed at "HIGH (Red)". The Emergency Severity Index Acuity was documented at "3 Urgent." The record revealed the ED provider saw the patient at 7:13PM. Labs were drawn. The Crisis Center was contacted and a crisis center worker came to the ED to evaluate the patient at 7:46PM. "ED Provider Notes Impression and Plan revealed, "NW Connections (Crisis Center) saw patient in person and discussed with family, and they are agreeable to discharge." Written discharge instructions were given and the patient was discharged to home with parents at 9:01PM.
There is no documentation in the medical record to demonstrate ongoing nursing assessments or suicide precautions taken for the 1 hour and 54 minutes while a patient in the ER. The record reveals vital signs on admission at 7:07PM and 7:43PM.


Review of Pt. #16's medical record on 3/2/20 revealed a [AGE] year old admitted on [DATE] at 2:01PM after intentionally ingesting 20-30 pills in a suicide attempt. The record revealed a Columbia-Suicide Severity Rating was performed at 2:28PM by the ED nurse with the severity level assessed at "HIGH (Red)". The Emergency Severity Index Acuity was documented at "2 Emergent." The record revealed the ED provider saw the patient at 2:29PM. Labs were drawn and a heart tracing performed. The "ED Provider Notes" revealed, "states she was trying to kill herself and still feels that way somewhat. 1 previous attempts at overdose." "ED Course" revealed, "2:59PM discussed with poison control...advised 6-hour monitoring for CNS (central nervous system) depression, seizure primarily." "ED Nurses Notes" at 3:00PM revealed, "Patient's significant other in the room for patient safety." A Tele-psychiatry consult by Health Partners was performed at 7:08PM. The Health Partners note revealed, ""Suicide Risk Level High... Pt. agreed to a safety plan along with boyfriend. Pt. said she would not go to hospital voluntarily and does not qualify for Chapter... Pt. denies current S.I. (suicidal ideation). "ED Provider Notes ED Course reveal 5:10PM Reeval.(reevaluation) Feels same. Mild HA (headache) and nausea. 7:00PM: Reeval. Feels better. Medically cleared. Impression and Plan...The patient was discharged in stable condition. We discussed reasons to return and follow up." Written discharge instructions were given and the patient was discharged to home with boyfriend at 8:40PM.
There is no documentation in the medical record to demonstrate ongoing nursing assessments or suicide precautions taken for the 6 hour and 39 minutes while a patient in the ER. "ED Nurses Note" at 3:00PM reveals "Patient's significant other in the room for patient safety" no notes confirming ongoing presence. Record revealed every 15 minute vital signs documented from 4:17PM to 6:30PM. At 4:27PM "ED Stabilization and Reassessment Scale" revealed "Level 2 (Emergent).


Review of Patient #22's medical record on 3/3/20 revealed a [AGE] year old admitted on [DATE] at 4:03PM via law enforcement for medical clearance for depression and suicidal ideation. Nurses Note reveal, "pt had a gun". The record revealed a Columbia-Suicide Severity Rating was performed at 4:16PM by the ED nurse with the severity level assessed at "HIGH (Red)". The Emergency Severity Index Acuity was documented at "3 Urgent." The record revealed that the ED provider saw the patient at 4:04PM. Labs and heart tracing were ordered and performed. "ED Provider Notes Impression and Plan: ...Patient has been medically cleared and will be transferred to a psychiatric facility." The patient was discharged at 7:47PM and transported to Psychiatric Hospital C by law enforcement.
There is no documentation in the medical record to demonstrate ongoing nursing assessments or suicide precautions taken for the 3 hour and 45 minutes while a patient in the ER. The record reveals vital signs on admission at 4:14PM. At 6:44PM "ED Stabilization and Reassessment Scale" revealed "Level 4 (Semi-Urgent).

In interview with In-patient Manager A on 3/2/20 at 1:05PM when asked about the policy and standard of care for care and observation of high suicide risk patients in the ED stated, "We don't have a policy but I would expect to see something regarding 1:1 provided or placed on precautions." When asked about a ligature safe room in the ED In-patient Manager A stated, "We really don't have one. I would think that staff removes some equipment and supplies from the room but it's obviously not documented in any of these medical records." Questioned regarding the Columbia Suicide assessment and levels, asked "What do the different levels mean? What is staff supposed to do based on the levels?" Responded, "I guess we don't define that very well." Inquired about suicide precautions for in-patients that may be admitted with mental health issues In-patient Manager A stated, "We wouldn't admit those patients, we would transfer them. We have provided 1:1 on the in-patient unit but it's usually for high fall risk patients."

In interview with DON B on 3/2/20 at 3:00PM it was confirmed. "No we don't have any policies on suicide precautions, probably should though."